Provider Demographics
NPI:1326701954
Name:DETRICK, JESSICA BOND
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:BOND
Last Name:DETRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3435 S 4TH AVE LOT 10
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85365-4345
Mailing Address - Country:US
Mailing Address - Phone:928-304-1542
Mailing Address - Fax:
Practice Address - Street 1:3435 S 4TH AVE LOT 10
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85365-4345
Practice Address - Country:US
Practice Address - Phone:928-304-1542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-20
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Multi-Specialty